Basic Information
| Provider Information | |||||||||
| NPI: | 1528245438 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 100 ROGERS OPERATING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 NE 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7868883310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 ROGERS LN | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448751759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193471313 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUAY | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7868883310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | C.P.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2819347 | 05 | OH | MEDICAID |